Alessandro Coppola

Laparoscopic pancreatoduodenectomy: current status and future directions

In recent years, laparoscopic pancreatoduodenectomy (LPD) has been gaining a favorable position in the field of pancreatic surgery. However, its role still remains unclear. This review investigates the current status of LPD in high-volume centers. A literature search was conducted in PubMed, and only papers written in English containing more than 30 cases of LPD were selected. Papers with “hybrid” or robotic technique were not included in the analysis. Out of a total of 728 LPD publications, 7 publications matched the review criteria. The total number of patients analyzed was 516, and the largest series included 130 patients. Four of these studies come from the United States, 1 from France, 1 from South Korea, and 1 from India. In 6 reports, LPDs were performed only for malignant disease. The overall pancreatic fistula rate grades B–C were 12.7%. The overall conversion rate was 6.9%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. However, the lack of many large series, multi-institutional data, and randomized trials does not allow the clarification of the exact role of LPD.

Primary hepatic angiosarcoma.

Primary hepatic angiosarcoma is a rare entity, representing only 4% of all the angiosarcomas of different origins and less than 1% of all hepatic malignancies. Accurate diagnosis of this tumour is difficult, especially if the patient has no history of exposure to specific carcinogens including thorotrast, arsenicals and vinyl chloride monomer. Angiosarcoma, a subtype of soft tissue sarcoma, is an aggressive malignant disease deriving from endothelium, lymphatics or blood vessels. Some of the more common hepatic sarcomas are angiosarcoma, embryonal sarcoma, leiomyosarcoma, epithelioid hemangioendothelioma, fibrosarcoma and malignant fibrous histiocytoma. The survival of hepatic angiosarcoma is very poor, which is attributable to its rapid progress, high recurrence rate and resistant to traditional chemotherapy and radiotherapy. The survival of patients with liver angiosarcoma is very poor with median survival of 6 months without treatment; after treatment, only 3% of patients were reported to live longer than 2 years. To date, the therapeutic guideline for liver angiosarcoma has not been set up, so partial liver resection to remove tumour radically still remains to be the cornerstone of treatment options. A 72-year-old woman presented at the emergency department of our hospital with abdominal pain, fever (38.8°C), nausea and vomiting. Blood haemoglobin was 7.7 g/dL, white blood cell count was 19.500 × 10/L, platelet count was 322.000 × 10/L, the international normalized ratio was 1.52 and prothrombin activity was 51% of standard. Six months earlier, the patient had undergone abdominal ultrasound and contrast-enhanced computed tomography (CT) scan because of mild abdominal pain located in right upper quadrant. These examinations documented an 18-cm mass of the right hemiliver which presented delayed and homogeneous enhancement and features consistent with hepatic haemangioma, which was the final diagnosis. At that time, liver resection was not advised because the hemangioma had only been moderately symptomatic. Now, in the emergency department, a new abdominal CT scan documented an increase in the size of the mass (22 × 15 × 18 cm). During the arterial phase, the mass presented a peripheral enhancement; during the portal phase, the globular enhancement moved centripetally and during the delayed phase, there was a more intense peripheral enhancement with some enhanced intralesional foci. The middle and left hepatic veins were compressed and dislocated by the mass (Fig. 1). The patient was scheduled for liver resection with the presumptive diagnosis of symptomatic giant haemangioma complicated by anaemia, coagulopathy and fever. The patient underwent right hepatectomy and the post-operative course was uneventful (Figs 2,3). At pathology, the final diagnosis was primary hepatic angiosarcoma. Unlike most hepatocellular carcinomas, hepatic angiosarcoma does not arise in a background of chronic viral hepatitis. Primary Fig. 1. Abdominal computed tomography scan: huge hypodense hepatic mass which involves the right hemiliver (22 × 15 × 18 cm).

The impact of R1 resection for colorectal liver metastases on local recurrence and overall survival in the era of modern chemotherapy: An analysis of 1,428 resection areas

Background: It is still unclear whether a positive surgical margin after resection of colorectal liver metastases remains a poor prognostic factor in the era of modern perioperative chemotherapy. The aim of this study was to evaluate whether preoperative chemotherapy has an impact on reducing local recurrence after R1 resection, and the impact of local recurrence on overall survival. Methods: Between 2000 and 2014, a total of 421 patients underwent resection for colorectal liver metastases at our unit after preoperative chemotherapy. The overall number of analyzed resection areas was 1,428. Results: The local recurrence rate was 12.8%, significantly higher after R1 resection than after R0 (24.5% vs 8.7%; P < .001). These results were also confirmed in patients with response to preoperative chemotherapy (23.1% after R1 vs 11.2% after R0; P < .001). At multivariate analysis, R1 resection was the only independent risk factor for local recurrence (P < .001). At the analysis of the 1,428 resection areas, local recurrence significantly decreased according to the increase of the surgical margin width (from 19.1% in 0 mm margin to 2.4% in ≥10 mm). At multivariable logistic regression analysis for overall survival, the presence of local recurrence showed a significant negative impact on 5‐year overall survival (P < .001). Conclusion: Surgical margin recurrence after modern preoperative chemotherapy for colorectal liver metastases was still significantly higher after R1 resection than it was after R0 resection. Local recurrence showed a negative prognostic impact on overall survival. R0 resection should be recommended whenever technically achievable, as well as in patients treated by modern preoperative chemotherapy.

Anatomical liver resection of segment 4a en bloc with the caudate lobe

Anatomical segmentectomy is the complete resection of an area supplied by a segmental portal branch. Among segmentectomies, isolated segmentectomy 4 is a technically demanding procedure because there are two transection planes: on the left side along the umbilical fissure and, on the right side, along the middle hepatic vein. Although there are several reports on anatomic segmentectomies, only few regard the anatomic segmentectomy 4a. We report here the case of a 60‐year‐old man who underwent anatomical segmentectomy 4a en bloc with the caudate lobe to resect a colorectal liver metastasis located in segment 4a and involving the paracaval portion of the caudate lobe. This type of procedure was planned in order to maximize the postoperative functional hepatic reserve, thereby reducing the risk of postoperative liver failure and ultimately allowing the possibility for future repeat hepatectomy in case of recurrence. J. Surg. Oncol. 2016;113:665–667.